Basic Information
| Provider Information | |||||||||
| NPI: | 1740664226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | GLENDA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 128 DANIEL AVENUE | ||||||||
| Address2: | |||||||||
| City: | BOONEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729276502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796752455 | ||||||||
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| Practice Location | |||||||||
| Address1: | 128 DANIEL AVENUE | ||||||||
| Address2: | |||||||||
| City: | BOONEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729276502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796752455 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2015 | ||||||||
| LastUpdateDate: | 07/15/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | A004464 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LF0000X | A004464 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.